Maryland Pre-hospital Protocol for Croup

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Maryland Pre-hospital Protocolfor Croup
Maryland EMSC Program
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Care for Children with Croup

• Developed by
• Hopkins Outreach for Pediatric Education
• Written by
• Elizabeth Berg, RN, BSN, EMT-B
• Reviewed by Maryland PEMAG 7/2001

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Objectives

• Identify three signs and symptoms of croup
• State the treatment protocol for croup
• List two criteria for medical direction
• Identify three signs and symptoms of pediatric
  respiratory failure
• List two criteria for BVM ventilations

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Epidemiology of Croup

• Common age range is 3 months to 4 years
• Most severe symptoms under 3 years
• More common in males
• Most common during the winter months
• Typical duration of illness is 5-6 days

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Pathophysiology of Croup

• Viral infection of the vocal cords
• Parainfluenza virus (75)
• Adenovirus
• Respiratory syncytial virus (RSV)
• Influenza
• Measles
• Bacterial super infection

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Pediatric Anatomical and Physiological
Differences

• Airway shape cone versus cylindrical
• Narrowest point at the cricoid ring
• Anterior vocal cords
• Tongue larger in proportion to the mouth

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Airway Differences
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Pediatric Anatomical and Physiological Differences

• Smaller, more collapsible lower airways
• Diaphragm dependent
• Poorly developed intercostal and accessory
  muscles

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Clinical Presentation of Croup

• Signs and symptoms
• Loud barking cough
• Hoarseness
• Respiratory distress
• Nasal flaring
• Retractions
• Head-bobbing
• Inspiratory grunting or stridor

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Clinical Presentation of Croup

• Associated illnesses
• Ear infection
• Pneumonia

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Neck X-rays
Normal Airway
Narrowed Airway
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Other Causes of Pediatric Airway Obstruction

• Vascular Ring
• Blood vessels compress the trachea
• Tracheomalacia
• Softening of the tracheal wall
• Foreign body
• Epiglottitis

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Epiglottitis

• Clinical presentation
• Over 5 years of age
• Most common organism is Hemophilus influenza
• Rapid onset of stridor and drooling
• Associated with high fever

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Epiglottitis

• Interventions
• High flow oxygen
• Calm environment
• No manipulation of the upper airway
• Hospital notification
• Do not initiate croup protocol

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EMS Protocol for Croup

• Initiate General Patient Care
• Allow children to assume their own position of
  comfort
• Semi-fowlers position will promote diaphragm
  expansion
• Allow parent to remain with child for emotional
  support

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EMS Protocol for Croup

• Initiate General Patient Care
• Get down to childs level
• Use age-appropriate words
• Give them choices, when able
• If stable, allow the child to set the pace of the
  procedure

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EMS Protocol for Croup

• Initiate General Patient Care
• Foster trust by telling the truth
• Be aware of the capabilities of the local ED
• Consider risks and benefits of transporting the
  child to a pediatric referral center
• Administer oxygen without increasing agitation

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Oxygen Administration in Children

• Infants/toddlers may not tolerate a face mask
• Have parent hold mask near patients face
• Place oxygen tubing set at 10 lpm in the bottom
  of a paper cup with stickers inside
• Use commercially designed teddy-bears with oxygen
  port may also use for nebs

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EMS Protocol for Croup

• Presentation
• Severe Priority 1
• Unable to speak or cry
• Decreased LOC
• Bradycardia or tachycardia
• Hypertension or hypotension

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EMS Protocol for Croup

• Presentation
• Moderate Priority 2
• Slow onset of respiratory distress
• Barking cough
• Fever
• Audible stridor

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EMS Protocol for Croup

• Treatment
• Perform initial patient assessment
• Patent airway
• Adequate respiratory effort
• Assign a treatment priority
• If patient gt 40 kg (88 lbs) treat under adult
  protocol

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Continuum of Respiratory Failure
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EMS Protocol for Croup

• Treatment
• Place on cardiac monitor, pulse oximeter
• Record vital signs
• Initiate IV with LR at a KVO rate
• Do not withhold epinephrine if IV not easily
  obtainable
• Over 75 of croup cases seen in ED have no IV
• If patient is unstable, establish IO access

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EMS Protocol for Croup

• Under 40 kilograms with S/S of croup
• Administer 3 cc of NS via nebulizer for 3-5 mins
• Continue NS nebulization during transport if
  improved
• If no improvement, contact medical control
  physician to administer inhaled epinephrine
• All patients who receive nebulized epinephrine
  must be transported by an ALS unit to the hospital

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EMS Protocol for Croup

• Obtain medical direction
• Give 2.5 ml of 11000 epinephrine via nebulizer
• A second dose may be given with medical direction
  
• Other interventions, such as albuterol neb
• Albuterol and epinephrine are compatible

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Pharmacological Actions of Inhaled Epinephrine

• Alpha-adrenergic receptor agonist
• Desired action
• Local vasoconstriction in the large airways,
  which reduces airway edema and obstruction
• Caution may have rebound edema
• Decreased systemic effects with inhalation

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EMS Protocol for Croup

• Imminent respiratory arrest
• Administer 0.01 mg/kg of 11000 epinephrine SC
• Max dose is 0.3 mg
• Interventions for pediatric respiratory failure
• Bag-valve-mask ventilations
• May administer inhaled medications with BVM
• Endotracheal intubation

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BVM with Multi-Dose Inhalor Port
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BVM with In-line Nebulizer
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Criteria for BVM Ventilations

• Inadequate RR
• Infant/Toddler lt 20
• Child lt 16
• Adolescent lt 12
• Bradycardia
• Infant HR lt 80
• Child HR lt 60

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Criteria for BVM Ventilations

• Inadequate respiratory effort
• Absent or diminished breath sounds
• Paradoxical breathing
• Cyanosis on 100 oxygen
• Cardiac arrest
• Altered mental status
• GCS lt 8

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Complications of BVM Ventilations

• Gastric distension
• Vomiting
• Increased ICP due to vagal stimulation
• Pressure over the eyes

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Equipment for BVM Ventilations

• Appropriate size mask
• Premature infants 0 Neonatal
• Newborn - 1 year 1 Infant
• 1 - 6 years 2 Toddler
• 6 - 12 years 3 Pediatric
• 12 years - young adult 4 Small Adult

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Equipment for BVM Ventilations

• Suction
• Appropriate size airway adjunct
• Appropriate size bag
• Newborn - 3 mo Neonatal 450 - 500 ml
• Child lt 30 kg Pediatric 750 ml
• Child gt 30 kg Adult 1000 - 1200 ml

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Single Provider Technique
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Two Provider Technique
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Respiratory Rates for Assisted Ventilations

• Infant/Toddler 30 - 40
• Child 20 - 30
• Adolescent 12 - 20

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Evaluate BVM Ventilations

• Chest rise and fall
• Presence of breath sounds
• Skin color
• Pulse oximeter reading
• Presence of end-tidal C02

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Troubleshooting BVM Ventilations

• Check size and seal of the mask
• Verify oxygen source
• Assure proper airway position

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Troubleshooting BVM Ventilations

• Disable the pressure pop-off valve
• Increase the size of the bag
• Treat gastric distension
• ALS providers insertion of gastric tube

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PRESENTATION

• Paramedics responded to a call for trouble
  breathing. Upon arrival they found a six month
  old with audible inspiratory stridor.
• Mom reports that pt was recently discharged after
  a work-up for a platelet disorder. He was having
  stridor last night, but was much improved this
  AM. No other past medical history or allergies.

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VITAL SIGNS

• PULSE 140-160
• ECG ST without ectopy
• RR 30-50, labored
• O2 SAT 90 on room air
• BP 84/45
• SKIN Pale, warm, moist
• WEIGHT Estimated at 10 kg

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FIELD MANAGEMENT

• Pt was kept calm in Moms arms for transport
• Inhaled saline at 6 LPM which brought the 02 sat
  up to 96.
• Parents refused an IV due to pts low platelet
  count.

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E. D. MANAGEMENT

• Upon arrival, chest x-ray done and pt placed on
  humidified oxygen.
• Pt received two racemic epi nebs with no
  improvement.

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E. D. MANAGEMENT

• Transport team contacted and recommended another
  racemic epi neb, an albuterol neb, and an IM dose
  of steroids.
• Parents finally consented to peripheral IV
  insertion.

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TRANSPORT TEAM MANAGEMENT

• Upon arrival the pt was gray and gasping for air
  with RR of 16.
• Transport RN and MD agreed pt needed emergent
  intubation. Pt received IV sedation with
  fentanyl and versed and was intubated with 3.5
  uncuffed ET tube.

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TRANSPORT TEAM MANAGEMENT

• CXR showed right mainstem intubation. ET tube
  was pulled back.
• Pt transported to the PICU without incident.

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DISPOSITION

• Within twelve hours of admission pt developed a
  leak around the ET tube and was successfully
  extubated.
• He was discharged from the hospital three days
  later with no ill effects.